Healthcare Provider Details

I. General information

NPI: 1548015738
Provider Name (Legal Business Name): ANTOINE ROYCE COLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4469 OXBRIDGE LN
STOW OH
44224-5358
US

IV. Provider business mailing address

4469 OXBRIDGE LN
STOW OH
44224-5358
US

V. Phone/Fax

Practice location:
  • Phone: 216-645-4929
  • Fax:
Mailing address:
  • Phone: 216-645-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberRT603035
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: